A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
Administer aspirin.
Measure blood pressure.
Administer nitroglycerin.
Initiate IV access.
The Correct Answer is C
Choice A reason: Administering aspirin is one of the first interventions for a client experiencing acute angina because aspirin has antiplatelet properties that help prevent blood clots, which can reduce the risk of a heart attack.
Choice B reason: Measuring blood pressure is important but not the first action to take. It provides valuable information about the cardiovascular status of the client and can influence further treatment decisions.
Choice C reason: Administering nitroglycerin is a priority action for acute angina as it helps to dilate the coronary arteries and relieve chest pain. However, it is typically administered after aspirin unless contraindicated.
Choice D reason: Initiating IV access is an important step in the management of acute angina, as it allows for the administration of medications and fluids if needed. However, it is not the first action to take during an acute angina episode.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Desmopressin is a medication used to treat conditions like diabetes insipidus and certain cases of hemophilia, not allergic reactions such as hives and urticaria.
Choice B reason: Diphenhydramine is an antihistamine that is commonly used to treat allergic reactions, including hives and urticaria. It works by blocking the action of histamine, a substance in the body that causes allergic symptoms.
Choice C reason: Spironolactone is a diuretic and is not used to treat allergic reactions. It is typically prescribed for conditions like heart failure, hypertension, and certain hormonal disorders.
Choice D reason: Metoclopramide is a medication used to treat nausea and gastroparesis, not allergic reactions.
Correct Answer is B
Explanation
Choice A reason: The fluctuation of fluid in the water-seal chamber does not necessarily mean that the lung is fully re-expanded. The water-seal chamber's fluid level fluctuates with the client's breathing because it reflects the changes in intrathoracic pressure.
Choice B reason: The statement "Your breathing pattern causes this" is correct. The fluctuation, also known as tidaling, in the water-seal chamber is normal and occurs in response to the client's breathing. When the client inhales, negative pressure in the chest cavity causes the fluid level to rise, and when the client exhales, the pressure becomes positive, causing the fluid level to fall.
Choice C reason: Suction pressure that is too high can cause continuous bubbling in the suction control chamber but does not directly cause the fluid in the water-seal chamber to rise and fall. The suction control chamber's bubbling should be steady and gentle when the suction is set correctly.
Choice D reason: Continuous bubbling in the water-seal chamber may indicate an air leak, which is a problem that needs to be addressed. However, normal fluctuation with breathing is not indicative of an air leak.
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